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pryUlN PAYMENT <br /> .SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTME <br /> SOV 10 2010 LOP <br /> : a 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION <br /> • .+ '.• SAN JOAQUIN COUNTY UNIT IV <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web:www.saalaytmlHM@niEAl .. <br /> HHT6EPAR'TMENT H <br /> WELL & BORING PERMIT APPLICATION <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION pQ2rI <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> / t <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Dee elopment Title,Chapter$-1115.3,and the <br /> ,Standards <br /> �of the San Joaquin County Environmental Health Department. <br /> Site Locati n 3•A'11 S-4-//U /20 Cross Street K/T%�fv �s _ City /yJ/,f Girf tCA Zip 7�5-33 & APN ZZ 6E)Z(3Zy <br /> Property,. J <br /> Owner S T - rL�'1hIL�/E S Address 5Q0�Y- ? <br /> e.-�-r/� ,�,.y, fV Wx 3. City Zip Phone <br /> C-57 Contractor gg,j4tltlfess /� -�.����5— City ,�"... .A a Lic Phone roll ' $ <br /> Consultant/Sub Cntr, �.! Net Address 1192 NPArtA, Ata* City ir.Ucn LicPhone Z61Z I <br /> Billable Party_ 'W 4-f O Address �r City �' Zip__Phone <br /> GIS Coordinates:X 37•TG3 Y (u. I �/ _ �.• ' i"�r <br /> CONSTRUCTION WORK TO BE PERFORMED: <br /> ❑NEW WELUBORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) <br /> ❑SOIL BORING IDs <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE 8#OF WELLIBORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: \ <br /> _❑EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER <br /> —❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE <br /> _❑SOIL BORING ❑PUSH POINT(GPI CPT) GROUT SEAL PUMPED:❑Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION ti.e Air Soarae Ozone ❑HAND AUGER GROUT SPECIFICATIONS <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE 1v <br /> COMMENTS: CONDUCTOR CASING❑No❑Yes:Casing Dia: Casing Depth: Bonng Dia'_ <br /> NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD: CHECI LL THAT APPLY c� <br /> -#OF WELLS)TO BE DESTROYED ER- IAMETER OF IN HES TO DEPTH OF •� FT <br /> WELL IDs: �/yf S' PRESSURE GROUT TO DEPTH OF <br /> �FT BELOW SURFACE <br /> GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED: AUGERS ❑HOSE ❑PIPE /0 Z E]MUSHROOM CAP AT(?3 FT) FT BELow SURFACE <br /> COMMENTS G—T. <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and all applicable-Caalifornia�la <br /> Signed '1A&j i�J E�LlLCc77i(�.��J Title/Company <br /> Print Name S �vtl r1/L Date &J/7--?�P <br /> DEPARTMENT USE OtN�LY � Z9•� <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS I T U D dN'Lf+c•Y�Y <br /> WORK PLAN DATED ! •23 • (D <br /> APPLICATION ACCEPTED BY DSTE ISSUEDII^ 5� .fY AREA <br /> GROUT INSPECTION BY FINAL INS ECT N BT--__ DA L 3-7446 <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: CO1tK- <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE <br /> REQUEST PR# <br /> 29D7— 1 $ 122. t 22 .0-D SR# 0 43 <br /> RO# <br /> 3500 <br /> ?9 0 oogz89 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT ENCROACHMENT DOC <br /> ERE,29-01 07/28/10 WELL pER ITRDQ APP , <br /> /�VyI{•Qpt_Q.C�CPsa �(vW71J►T-' <br />